1568732634 NPI number — GRAND RIVER BANDS OF OTTAWA INDIANS INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568732634 NPI number — GRAND RIVER BANDS OF OTTAWA INDIANS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND RIVER BANDS OF OTTAWA INDIANS INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568732634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2937
Provider Second Line Business Mailing Address:
1251 PLAINFIELD N.E.
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49501-2937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
671 DAVIS AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49504-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-451-6767
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
YOB
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
FRANCIS
Authorized Official Title or Position:
CHAIRPERSON
Authorized Official Telephone Number:
616-458-8759

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  410300 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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